<p> Mediation Request Form</p><p>Your Information Name: </p><p>Working Title: Work Phone: </p><p>Mailing Address: </p><p>E-mail: </p><p>Working Relationship to the Other Person</p><p>Supervises other person Supervised by other person Does not supervise the other person directly, but is in the other person’s chain of command Is not supervised by the other person, but the other person is in this employee’s chain of command Co-worker</p><p>Other Person Please fill out as much information as possible.</p><p>Name: </p><p>Working Title: Work Phone: </p><p>Mailing Address: </p><p>E-mail: </p><p>Other Person(s) involved</p><p>Names and Titles: </p><p>Work Phone: Address: </p><p>Relationship to you: </p><p>Who Referred You to Mediation? Self Agency Personnel Administrator Supervisor Other Co-worker Specify: Personnel Board</p><p>I am choosing mediation: as early intervention (there is no plan at this time to file grievance) in addition to the grievance / appeal board process after the conclusion of grievance process</p><p>Revised 04/09</p>